Searching in the Dark: Shining a Light on Non-Response to Psychotherapy for Borderline Personality Disorder

Background: Health practitioners have long recognised that a proportion of patients with Borderline Personality Disorder (BPD) struggle to improve even after being provided with evidence-based treatments. Despite this, there are few studies and little known about the size and factors behind non-response. This thesis by compilation presents three studies exploring non-response to psychotherapy for BPD. Method: First, a systematic review was conducted to obtain an informed estimate from the literature on the proportion of people who are not responding to psychotherapy for BPD (Chapter Two). Second, a quantitative study that sought to identify factors that may increase the likelihood of non-response to psychotherapy for BPD in 184 individuals after 12 months of treatment in the community was conducted (Chapter Three). Third, a qualitative study sought to understand the problem of non-response from the perspective of people with a lived experience of BPD. Thematic analysis was conducted on interviews regarding people’s insights into non-response to psychotherapy for BPD (Chapter Four). The thesis is concluded with a discussion of overall findings and future directions (Chapter Five). Results: The systematic review identified 28 studies that reported individual response rates to psychotherapy for BPD in 2436 people. Of these participants, M = 48.80% (SD = 22.77) did not respond to treatment (Chapter Two). The quantitative study (N = 18) revealed that preoccupied attachment style, dismissive attachment style, high anger and high paranoia were associated with increased likelihood of being a non-responder after 12 months of psychotherapy in the community (Chapter Three). The results of the qualitative study demonstrated that participants consistently attributed an unsafe therapeutic alliance as the main cause of non-response to psychotherapy for BPD (Chapter Four). Conclusion: As a whole, the present research has produced an informed estimate of the proportion of people who are not responding to psychotherapy for BPD, identified factors that increase the likelihood of non-response, and explored patient perspectives on non-response. The reasons for non-response appear complex and individual, although interpersonal fears of patients’ and struggles to relate well to therapists were prominent in the findings. Future research needs to extend further the personal and interpersonal factors that are making it hard for people to benefit from treatment.